Integrating Home Health Care into the Learning Health System for Enhanced Patient Care

Dr. Madeline Sterling emphasizes the importance of integrating home health care into the learning health system to improve care for patients with heart failure. Although learning health systems have been widely adopted in hospitals and outpatient networks, home health care remains largely excluded, particularly for older adults with heart failure. Integration of home health care into learning health systems would allow for real-time data sharing and better patient care, but barriers such as poor care coordination exist.

Key Takeaways:

• Dr. Madeline Sterling, Associate Professor of Medicine, and Dr. Lisa Kern, Professor of Medicine, emphasized the importance of integrating home health care into the learning health system to strengthen care for patients with heart failure.
• The learning health system (LHS) gathers data throughout the entire care process and leverages it to optimize treatments in real time, but integration with home health care services remains underdeveloped.
• Home health care services, provided by Medicare, include skilled nursing and physical therapy visits and some home health aide hours, with 1 out of 3 Medicare beneficiaries hospitalized for heart failure discharged home with these services.
• Patients at high risk for readmission can be curbed when home health care is delivered optimally, including home care nurse visits soon after the patient arrives home and timely outpatient medical visits with clinicians.
• Hospitals and outpatient networks have implemented LHS using electronic health records (EHRs) to store, analyze, and share patient data, but data from the home and home care agencies rarely makes it back to the hospital and ambulatory practices.
• Integration of home health care into LHS would allow data from home care visits to be used in real time for better patient care and to prevent complications.
• Barriers such as poor care coordination, between hospitals, home health agencies, and outpatient providers, exist, but implementation science can guide providers on adopting effective strategies for better healthcare delivery.
• Increased awareness from physicians is needed to refer patients to home health care and actively encourage its use, and hospitals and home health agencies can work to improve information sharing, particularly after a patient is discharged.

Statistics:

• 1 out of 3 Medicare beneficiaries hospitalized for heart failure are discharged home with home health care services (Source: Weill Cornell Medicine).
• Home health care services can curb readmissions when delivered optimally, including home care nurse visits soon after the patient arrives home and timely outpatient medical visits with clinicians (Source: Weill Cornell Medicine).
• Hospitals and outpatient networks have implemented learning health systems (LHS) using electronic health records (EHRs) to store, analyze, and share patient data, with rare exception of data from home and home care agencies (Source: Weill Cornell Medicine).

Sources:

• Weill Cornell Medicine
• National Heart, Lung, and Blood Institute (funding source for Dr. Sterling's R01 grant)